Another case for unilateral implantation is the child with profound developmental delay. “Two contraindications in our program for simultaneous cochlear implantation would be abnormal cochlear anatomy or substantial developmental delay which would make rehabilitation difficult,” Dr. Woolley said.
Explore This IssueJune 2010
Very young age of the patient and parental preference may also be reasons for unilateral implantation. “Bilateral surgery in a child under one year of age is a lot of surgery,” Dr. Buchman said. “Some families are not bought into the entire concept at that age. In less than a year, they’ve had a new baby, their baby is now thought to be severely hearing impaired…and they’re still in the process of figuring it out.”
According to Dr. Papsin, when factors outside of medicine and pure clinical benefit to the patient are considered, the argument seems to come down on the side of a single unilateral implant. The benefit to the patient of the first implant is significantly greater than that of the second. The first enables a deaf person to hear. The second provides qualitative improvements in the efficacy of this newfound hearing. If the two implants are done sequentially, doubling all the costs associated with a single procedure, a single cochlear implant is significantly more cost effective than two.
“The reason why is because the first one shows so much effectiveness [that] it’s close to near normal on the scales that we use. So, adding a second doesn’t seem to be cost effective,” Dr. Papsin said.
The Centers for Medicare and Medicaid Services (CMS) do reimburse for both unilateral and bilateral cochlear implants, under very specific conditions. According to the CMS website, “Effective for services performed on or after April 4, 2005, cochlear implantation may be covered for treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification.”
Despite the CMS policy, cost and reimbursement are among the main reasons children receive a single implant or that they receive two sequentially. In many cases, “it’s not favorable to the hospital to have a bilateral case because they may not get compensated very much for the second surgery,” Dr. Germiller said.